<%@ page language="java" contentType="text/html; charset=UTF-8"   pageEncoding="UTF-8"%>
<%@ taglib prefix="c" uri="http://java.sun.com/jsp/jstl/core"%>
<%@ taglib uri="http://java.sun.com/jsp/jstl/fmt" prefix="fmt" %>
<%@ taglib uri="http://www.acms.com/acmstag" prefix="acms" %>
<%
	String contextPath = request.getContextPath();
%>

<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=ISO-8859-1">
<link href="<%=contextPath%>/assets/stylesheets/bootstrap.min.css" rel="stylesheet" type="text/css">
<link href="<%=contextPath%>/assets/stylesheets/pixel-admin.min.css" rel="stylesheet" type="text/css">
<link href="<%=contextPath%>/assets/stylesheets/pages.min.css" rel="stylesheet" type="text/css">
<link href="<%=contextPath%>/assets/stylesheets/rtl.min.css" rel="stylesheet" type="text/css">
<link href="<%=contextPath%>/assets/stylesheets/themes.min.css" rel="stylesheet" type="text/css">
<link href="<%=contextPath%>/assets/stylesheets/select2.min.css" rel="stylesheet" type="text/css">
</head>
<body class="theme-default page-signup-alt">
	
	<form class="panel form-horizontal" id="jq-validation-form" method="POST" style="width:1000px">
		<input type='hidden' value="${caseFollowUp.followedType}" id="followedType"></input>
		<div class="row">
			<div class="col-sm-12">
				<div class="row">
					<div class="col-sm-12">
						<div class="form-group no-margin-hr">
							<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Has the
					 Abuse Case Been Contacted?</h1></label>
					 		<acms:disabledSelectTag label="${caseFollowUp.beenContacted }"/>
						</div>
					</div>
				</div>
			</div>
		</div>
		<c:if test="${caseFollowUp.beenContacted == '1'}">
		<div class="row">
			<div class="col-sm-2">
				<div class="form-group no-margin-hr">
					<label class="control-label">Date Contacted</label>
				</div>
			</div>
			<div class="col-sm-3">
				<label class="form-control"><fmt:formatDate value="${caseFollowUp.contactedDate}" pattern="MM/dd/yyyy"/></label>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">By Who?</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr" id="internationlType" style="display: none;">
					<label class="checkbox-inline">
						<input type="radio"  class="px" checked disabled> <span class="lbl">CCHR International</span>
					</label>			
				</div>
			</div>
		</div>
		<div class="row" id="internationlArea">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Staff Member First Name:</label>
						</div>
					</div>
					<div class="col-sm-6">
						<label class="form-control">${caseFollowUp.staffMemeberFirstName}</label>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Staff Member Last Name:</label>
						</div>
					</div>
					<div class="col-sm-6">
						<label class="form-control">${caseFollowUp.staffMemeberLastName}</label>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr" id="chapterType" style="display: none;">
					<label class="checkbox-inline">
					<input type="radio" class="px" checked> <span class="lbl" >CCHR Chapter</span>
					</label>			
				</div>
			</div>
		</div>
		<div class="row" id="chapterArea" style="display: none;" >
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Which Chapter?</label>
					<label class="form-control">${caseFollowUp.chapter}</label>
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Staff Member First Name</label>
					<label class="form-control">${caseFollowUp.staffMemeberFirstName}</label>
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Staff Member Last Name</label>
					<label class="form-control">${caseFollowUp.staffMemeberLastName}</label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-2">
				<div class="form-group no-margin-hr">
					<label class="control-label">Contacted by:</label>				
				</div>
			</div>
			<c:forEach var="contact" items="${contactWays }">  
	     			<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="checkbox-inline">
								<input type="checkbox" class="px" checked>${contact}</input>
							</label>			
						</div>
					</div> 
   			</c:forEach> 
		</div>
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Email</label>
					<label class="form-control">${caseFollowUp.staffMemeberEmail}</label>
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Phone Number</label>
					<label class="form-control">${caseFollowUp.staffMemeberPhoneNumber}</label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-1">
				<div class="form-group no-margin-hr">
					<label class="control-label">Notes</label>				
				</div>
			</div>
			<div class="col-sm-11">
				<div class="form-group no-margin-hr">
					<textarea readonly="readonly" class="form-control" name="contactedNotes">${caseFollowUp.contactedNotes }</textarea>
				</div>
			</div>
		</div>
		</c:if>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Did the Abused Person Use Insurance?</h1></label>
					<acms:disabledSelectTag label="${caseFollowUp.userInsurance}"/>
				</div>
			</div>
		</div>
		<c:if test="${caseFollowUp.userInsurance == '1'}">
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">If yes,what type was used?</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<c:forEach var="type" items="${insuranceType }">  
	     			<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="checkbox-inline">
								<input type="checkbox" class="px" checked>${type }</input>
							</label>			
						</div>
					</div> 
   			</c:forEach>			
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-6">
						<div class="form-group no-margin-hr">
							<label class="control-label">Insurance Company Name:</label>
						</div>
					</div>
					<div class="col-sm-6">
						<label class="form-control">${caseFollowUp.insurance1CompanyName}</label>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-6">
						<div class="form-group no-margin-hr">
							<label class="control-label">Insurance Company Name:</label>
						</div>
					</div>
					<div class="col-sm-6">
						<label class="form-control">${caseFollowUp.insurance2CompanyName}</label>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Notes on Insurance Details</label>				
				</div>
			</div>
			<div class="col-sm-9">
				<div class="form-group no-margin-hr">
					<label class="form-control">${caseFollowUp.notesOnInsuranceDetail}</label>
				</div>
			</div>
		</div>
		</c:if>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Attorney Status:</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<c:forEach var="type" items="${attorneyStatus }">  
	     			<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<label class="checkbox-inline">
								<input type="checkbox" class="px" checked>${type}</input>
							</label>			
						</div>
					</div> 
   			</c:forEach>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-6">
						<div class="form-group no-margin-hr">
							<label class="control-label">Attorney First Name</label>
						</div>
					</div>
					<div class="col-sm-6">
						<label class="form-control">${caseFollowUp.attorneyFirstName}</label>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-6">
						<div class="form-group no-margin-hr">
							<label class="control-label">Attorney Last Name</label>
						</div>
					</div>
					<div class="col-sm-6">
						<label class="form-control">${caseFollowUp.attorneyLastName}</label>
					</div>
				</div>
			</div>
		</div>
		 <div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Notes on Attorney status</label>				
				</div>
			</div>
			<div class="col-sm-9">
				<div class="form-group no-margin-hr">
					<textarea readonly="readonly" class="form-control">${caseFollowUp.notesOnAttorneyStatus}</textarea>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Abuse Case Referred to Attorney?</h1></label>
					<acms:disabledSelectTag label="${caseFollowUp.referAttorneyStatus}"/>
				</div>
			</div>
		</div>
		<c:if test="${caseFollowUp.referAttorneyStatus == '1'}">
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Attorney First Name</label>
					<label class="form-control">${caseFollowUp.referAttorneyFirstName}</label>
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Attorney Last Name</label>
					<label class="form-control">${caseFollowUp.referAttorneyLastName}</label>
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Date Referred</label>
						<label class="form-control"><fmt:formatDate value="${caseFollowUp.referAttorneyDate}" pattern="MM/dd/yyyy"/></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row col-sm-12">
					<div class="form-group no-margin-hr">
						<label class="checkbox-inline">
							<c:choose>
								<c:when test="${caseFollowUp.referAttorneyAccteptFlag == '1'}">
									<input type="checkbox" class="px" name="referAttorneyAccteptFlag" value="1" disabled checked="checked"> 
								</c:when>
								<c:otherwise>
									<input type="checkbox" class="px" name="referAttorneyAccteptFlag" disabled value="1"> 
								</c:otherwise>
							</c:choose>
							<span class="lbl">Accepted by attorney</span>
						</label>			
					</div>
				</div>
				<div class="row">
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Date Accepted</label>
						</div>
					</div>
					<div class="col-sm-9">
						<label class="form-control"><fmt:formatDate value="${caseFollowUp.referAttorneyAccteptDate}" pattern="MM/dd/yyyy"/></label>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row col-sm-12">
					<div class="form-group no-margin-hr">
						<label class="checkbox-inline">
						<c:choose>
							<c:when test="${caseFollowUp.referAttorneyDeclinedFlag == '1'}">
								<input type="checkbox" class="px" name="referAttorneyDeclinedFlag" value="1" disabled checked="checked"> 
							</c:when>
							<c:otherwise>
								<input type="checkbox" class="px" name="referAttorneyDeclinedFlag" value="1" disabled> 
							</c:otherwise>
						</c:choose>
						<span class="lbl">Declined by attorney</span>
						</label>			
					</div>
				</div>
				<div class="row">				
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Reason,if given</label>
						</div>
					</div>
					<div class="col-sm-9">
						<label class="form-control">${caseFollowUp.referAttorneyDeclinedReason}</label>		
					</div>
				</div>
				<div class="row">
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Date Declined</label>
						</div>
					</div>
					<div class="col-sm-9">
						<label class="form-control"><fmt:formatDate value="${caseFollowUp.referAttorneyDeclinedDate}" pattern="MM/dd/yyyy"/></label>	
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Notes on Attorney Referral</label>				
				</div>
			</div>
			<div class="col-sm-9">
				<div class="form-group no-margin-hr">
					<label class="form-control">${caseFollowUp.notesOnReferal}</label>	
				</div>
			</div>
		</div>
		</c:if>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Has a Complaint Been Filed on This Abuse?</h1></label>
					<acms:disabledSelectTag label="${caseFollowUp.filledWithAgency}"/>
				</div>
			</div>
		</div>
		<c:if test="${caseFollowUp.filledWithAgency == '1'}">
		<div class="row">
			<div class="col-sm-2">
				<div class="form-group no-margin-hr">
					<label class="control-label">Date Field</label>
				</div>
			</div>
			<div class="col-sm-3">
					<label class="form-control"><fmt:formatDate value="${caseFollowUp.filleWithAgencyDate}" pattern="MM/dd/yyyy"/></label>	
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Agency the Complaint Was Filed With:</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<label class="control-label">Agency Name</label>
						</div>
					</div>
					<div class="col-sm-8">
						<div class="form-group no-margin-hr">
							<label class="form-control">${caseFollowUp.filledAgencyName}</label>	
						</div>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<label class="control-label">Contact Name</label>
						</div>
					</div>
					<div class="col-sm-8">
						<div class="form-group no-margin-hr">
							<label class="form-control">${caseFollowUp.filledAgencyContactName}</label>	
						</div>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-4">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Street Address</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<label class="form-control">${caseFollowUp.filledAgencyAddress}</label>	
						</div>
					</div>
				</div>
			</div>
			<div class="col-sm-4">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">City/Province</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<label class="form-control">${caseFollowUp.filledAgencyCity}</label>	
						</div>
					</div>
				</div>
			</div>
			<div class="col-sm-4">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">State</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<label class="form-control">${caseFollowUp.filledAgencyState}</label>	
						</div>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<label class="control-label">Zip/Postal Code</label>
						</div>
					</div>
					<div class="col-sm-8">
						<div class="form-group no-margin-hr">
							<label class="form-control">${caseFollowUp.filledAgencyZip}</label>
						</div>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<label class="control-label">Country</label>
							
						</div>
					</div>
					<div class="col-sm-8">
						<div class="form-group no-margin-hr">
							<label class="form-control">${caseFollowUp.filledAgencyCountry}</label>
						</div>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-8">
						<div class="form-group no-margin-hr">
							<label class="control-label">Was a Response Received on the Complaint?</label>
						</div>
					</div>
					<div class="4">
						<acms:disabledSelectTag label="${caseFollowUp.compliantResponseReceived }"/>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">What Was the Response?</label>				
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<label class="form-control">${caseFollowUp.compliantResponseContent}</label>
						</div>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Notes on Complaint Field?</label>				
				</div>
			</div>
			<div class="col-sm-8">
				<div class="form-group no-margin-hr">
					<label class="form-control">${caseFollowUp.noteOnCompliant}</label>
				</div>
			</div>
		</div>
		</c:if>
		<hr>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-10">
						<div class="form-group no-margin-hr">
							<label class="control-label">Has the Abused Person Signed a General Waiver?</label>
						</div>
					</div>
					<div class="col-sm-2">
						<acms:disabledSelectTag label="${caseFollowUp.abusedPersonSigneWaiver}"/>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Date Signed</label>
						</div>
					</div>
					<div class="col-sm-8">
						<label class="form-control"><fmt:formatDate value="${caseFollowUp.abusedPersonSigneDate}" pattern="MM/dd/yyyy"/></label>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-10">
						<div class="form-group no-margin-hr">
							<label class="control-label">Has CCHR Received Documents From the Abused? </label>
						</div>
					</div>
					<div class="col-sm-2">
						<acms:disabledSelectTag label="${caseFollowUp.cchrReceivedAbusedDoc}"/>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Date Received</label>
						</div>
					</div>
					<div class="col-sm-8">
						<label class="form-control"><fmt:formatDate value="${caseFollowUp.cchrReceivedAbusedDocDate}" pattern="MM/dd/yyyy"/></label>
					</div>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Other Acitons Taken on the Case</label>				
				</div>
			</div>
			<div class="col-sm-8">
				<div class="form-group no-margin-hr">
					<textarea readonly="readonly" class="form-control">${caseFollowUp.otherActionsTaken}</textarea>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Currents Status on the Case</label>				
				</div>
			</div>
			<div class="col-sm-8">
				<div class="form-group no-margin-hr">
					<textarea readonly="readonly" class="form-control">${caseFollowUp.currentStatusOnCase}</textarea>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-8">
				<div class="row">
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<label class="control-label">Date Case was Last Updated</label>
						</div>
					</div>
					<div class="col-sm-8">
						<label class="form-control"><fmt:formatDate value="${caseFollowUp.caseLastUpdatedDate}" pattern="MM/dd/yyyy"/></label>
					</div>
				</div>
			</div>
			<div class="col-sm-3">
				<div class="row">
					<div class="col-sm-6">
						<div class="form-group no-margin-hr">
							<label class="control-label">Case Category </label>
						</div>
					</div>
					<div class="col-sm-6">
						<div class="form-group no-margin-hr">
							<select>
								<option>${caseFollowUp.caseCategory}</option>
							</select>
						</div>
					</div>
				</div>
			</div>
		</div>
		<br>
	</form>



	
<!-- Javascript -->
	<script>
		init.push(function () {

			$('.bs-datepicker-component').datepicker();
			
			var options2 = {
				orientation: $('body').hasClass('right-to-left') ? "auto right" : 'auto auto'
			}
			$('#bs-datepicker-range').datepicker(options2);
			
			$("#chapterType").hide();
			var type =$("#followedType").val();
			if(type=="CCHR International"){
				$("#internationlType").show();
				$("#internationlArea").show();
				$("#chapterType").hide();
				$("#chapterArea").hide();

			}else{
				$("#internationlType").hide();
				$("#internationlArea").hide();
				$("#chapterType").show();
				$("#chapterArea").show();

			}
		});

	</script>

</body>
</html>